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Medical Policy Update: Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer

Effective February 14, 2019, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider certain claims based on the revised guidelines of our medical policy, Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer.

Access our Medical Policy Manual to review this medical policy content.¹


Based on the submitted diagnosis code(s), claims for services provided on and after February 14, 2019, to patients enrolled in Horizon BCBSNJ Medicare Advantage (MA) plans will be processed as follows.

  • Medical record information may be requested to help us determine the medical appropriateness of the services represented by CPT® code 81519 included on claims for services provided to patients enrolled in Horizon BCBSNJ Medicare Advantage plans.

    Following our review of medical record information, the service represented by this code may be denied as an experimental/investigative, non-covered service.

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been cancelled or postponed, the changes will be applied to claims for services on and after February 14, 2019.

¹ The content of Horizon BCBSNJ medical policies that apply to Horizon BCBSNJ MA plans may include reference to pertinent National Coverage Determinations (NCDs) and/or Local Coverage Determinations (LCDs). We follow Centers for Medicare & Medicaid Services (CMS) guidelines, NCDs and/or LCDs in our processing of claims for services provided to our MA members. For those services where no LCD or NCD exists, claims for MA members will be processed based on our policy guidelines.

Published on: January 14, 2019, 14:15 p.m. ET
Last updated on: January 14, 2019, 14:16 p.m. ET